If you watch enough football (or follow sports at all), you’ve assuredly heard about players suffering a concussion or multiple concussions, resulting in their leaving a game, skipping a season, or even retiring permanently. Athletics may be the most publicized cause of this injury, but concussions occur frequently in the general public too, especially among children and the elderly.
A concussion is one of many types of traumatic brain injuries (TBI) and is often referred to as a mild traumatic brain injury (mTBI). It’s also the most common form of TBI. The consequences of a concussion can be minor, resolving within minutes to days, or more serious, causing a disruption in normal life and taking several weeks or longer to abate.
While a concussion may be referred to as a mild TBI, there is nothing mild about this kind of injury. It is mild only as it relates to more serious forms of TBIs. Even a singular first-time concussion with seemingly transient symptoms should be taken seriously.
As such, today I’ll walk you through how concussions happen, what they “look” like, and how they should be treated, so that you’re better prepared to take care of yourself and others in the face of an injury to this most essential part of the body.
What Exactly IS a Concussion?
To understand the nature of concussions, you first need to understand a bit about brain anatomy.
The brain is encased in the skull, which, some may be surprised to learn, is not a perfectly smooth structure. Instead, the internal surface is etched with valleys, ridges, and pockets of bone throughout. These grooves and inner structures support the brain and blood vessels and many other structures that make everything north of our necks work how they should.
The brain itself is a soft structure, with a consistency that many who’ve felt it firsthand have described as similar to Jell-O. (Check out this video for a great display of what a brain looks like fresh from autopsy; warning: not for those with a weak stomach!) As such, the brain is very vulnerable to damage, and the body has certain buffers in place to protect it and the spinal cord: a triple layer of membranes (meninges) and cerebrospinal fluid (CSF). Under normal conditions, CSF, among other functions, provides buoyancy to the brain and acts as a kind of shock absorber for it.
A concussion changes this healthy stasis, surmounting the brain’s natural protections, and turning the skull’s textured landscape into a tool of trauma.
A concussion can occur as a result of either a contact injury or a force injury (or in some unlucky cases, both). Taking a punch to the face would be a contact injury. Conversely, whiplash or blast injury, where the head is violently shaken without any actual contact with an external object or surface, would be a force injury. When a contact injury or acceleration force is strong enough, the brain tissue will come in direct contact with the interior of the skull, causing damage to blood vessels and neurons. Aside from this direct contact, the brain is stretched and compressed as it moves around, resulting in additional damage and disruptions.
During a traumatic impact, the brain is often damaged in the same area of the head that received the impact; if the left side of the head is struck, the left side of the brain is damaged. But the damage is not limited in this way. Just as when you shake a mold of Jell-O and it shifts one way and then the other, with strong enough impact or acceleration force, the brain strikes one side of the skull but instead of returning to its original position, it continues moving and strikes the other side of the skull, causing further damage to another area of the brain.
The brain contains different lobes, cortices, and other areas, all of which correspond with specific functions. Physical damage to the brain may have transient or permanent effects related to/based on which of these parts are affected. For instance, damage to part of the frontal lobe can result in mood swings and changes in personality. Damage to the occipital lobe, or rear of the brain, can result in temporary or permanent loss of vision. Whether the damage to the brain that a concussion causes is temporary or permanent depends on its severity.
Risk Groups and Factors
Exact numbers for concussions specifically are difficult to come by (due in part to underreporting), but according to the CDC there were about 2.5 million TBI-related emergency department visits in 2014 (this includes injuries more severe than concussions and patients with multiple injuries, including brain injuries).
Concussions are most commonly sustained in vehicle collisions, sports, and especially falls (which alone account for 47.9% of TBIs). The particular risk factors related to mTBIs are largely associated with age, though other circumstances play a role as well:
Children, Newborn-4 Years
For the first few years, our kids walk around like Bambi fresh out of the womb. That, and even as they get older, they don’t always pay a lot of attention to where they’re going. Anatomically, the heads of small children are bigger relative to their body than those of adults and their neck muscles are still developing. As they grow, their heads end up at counter height, table height, and every-other-hard-surface-with-a-sharp-corner height. Between tripping over their own feet, being top heavy, and running straight into anything slightly above eye level, little kids hit their heads a lot. Some of these injuries are of the kiss-where-it-hurts-now-go-play variety, but others can be quite significant.
Adolescence/Early Adulthood, 15-24 Years
The biggest risk factor of this age group is . . . risky behavior. Participation in team sports, extreme sports, driving too fast, showing off, and generally poor decision making lead to increased risk of damaging your dome.
Elderly, 60+ Years
By far, the majority of head injuries I treat are from elderly patients as a result of a fall. As we age, a number of physiologic and pathologic changes occur that lead to a heightened risk of falling. Some common causes include: musculoskeletal injuries and pathologies that lead to muscle weakness and unstable joints; diabetic neuropathy which commonly affects the feet and legs; generally poor gait and balance from a variety of causes; orthostatic hypotension (sudden drop in blood pressure when moving from sitting to standing); stroke-induced neurologic deficits that can cause weakness; and many, many more. And sometimes Grandpa is simply stubborn and unhappy about his loss of independence and refuses to use his walker. Combine all these factors with a slower reaction time, and more and more basic activities become risky behavior for this age group — like attempting the hike from the bed to the toilet. Unfortunately, elderly patients are also unable to effectively break their fall and end up taking the brunt of the impact force to their head.
Males, Any Age
Yup, just being male means we have a greater risk of head injuries (any injury, really). Between enjoying risky leisure activities, working dangerous jobs, and our undying tendency to show off and one-up each other, we put ourselves at risk of injury all the time. It’s just who we are.
Within the dangerous job category, men make up 85% of the military, and 97.5% of those in combat roles, which exposes them to a greater risk of concussion. Blast concussions are most common among military members and result from over-pressurization that the explosion causes, though direct trauma from debris can also cause a TBI.
Previous Concussions or Head Injuries
Having multiple prior concussions will affect the brain differently than a singular isolated concussion. Multiple concussions over time can cause greater effects on mood and sudden mood changes and slower neurologic recovery. The symptoms can last longer and take longer to recover. Eventually, repeated head trauma can lead to a condition called Chronic Traumatic Encephalopathy (CTE). CTE results in symptoms such as depression, impaired cognition, suicidal thoughts, emotional instability, and others. Physically, the brain itself atrophies, and the condition is similar to other brain pathologies such as dementia and Alzheimer’s. CTE is a difficult condition to diagnose; while it can be suspected in a living patient based on symptoms, a definitive determination of its existence can only be made during a post-mortem autopsy.
Signs and Symptoms of Concussions
So what does a concussion “look” like? How can you identify that you or someone else has experienced a concussion?
Common signs and symptoms of concussion and head injury can include:
- temporary loss of consciousness (getting “knocked out”)
- visual disturbances (seeing spots, blurred vision, etc.)
- sensitivity to noise and/or light
- nausea with or without vomiting
- differently sized pupils
- confusion
- headache
- dizziness
- feeling fatigued or tired
- loss of memory of the event
- irritability, mood swings
Some physical signs you might expect to see can include a laceration (or cut) at the site of impact along with bruising and swelling. However, in the case of things like whiplash or the blast from an explosion, a person may be outwardly unmarked, while sustaining unseen injuries to their brain.
Other symptoms of a concussion are noticeable after the initial event and can last from a few days to a few months, depending on severity. These post-concussion syndrome symptoms include:
- difficulty focusing
- behavioral changes (irritability, impulsivity, irrational behavior, low motivation)
- mood swings, changes in emotions
- new onset speech difficulties (a new stutter, for example)
- memory loss (this may be memory of the event, or other memory impairments such as forgetting why you walked into a room, losing your train of thought easily or frequently, etc.)
A few, more serious, pathologies that may result from head injury can include skull fractures, brain swelling, bleeding in the brain, and strokes. All of which can lead to further complications with potentially fatal effect. Swelling or bleeding inside the brain is especially dangerous, as the cranium is enclosed and there is nowhere for the swelling or blood to go, resulting in pressure on the brain. As the swelling or bleeding increases, the symptoms worsen, and the patient’s condition deteriorates.
Other signs or symptoms to watch for that may be indicative of these more serious conditions include:
- obvious open skull fracture
- depressed area of the skull
- altered mental status
- loss of consciousness without a return to consciousness
- loss of consciousness that resolves followed by a second loss of consciousness
- projectile vomiting
- appearing very sleepy or lethargic and difficult to rouse
- uneven, irregular, or slow breathing
- weakness in extremities or on one side of the body (as you might expect in a stroke)
- severe mood swings, irrational behavior, violent/aggressive behavior
- amnesia
- bleeding from one or both ears
When Should You Seek Medical Attention for a Possible Concussion?
Earlier in this article, I mentioned that exact numbers of concussions suffered nation-wide are hard to come by due to underreporting. Some people with only mild concussion symptoms don’t seek care, preferring to shake it off and give it the “wait and see” approach. “If symptoms improve, great. If not, well, I’ll go to my doctor later.”
This is certainly understandable. We’ve all been there. If it’s a minor injury, with little more than a goose egg and a headache to show for it, who wants to sit around an ER only for the doc to come in and give you the ole, “Let’s keep an eye on you for a few hours” without so much as an IV or CT scan to show for your trouble? Nobody, that’s who. Use your practical wisdom in these cases of minor trauma. But if something doesn’t seem right or you feel off in any way, just go.
If any of the following symptoms are observed, though, you should call 911 (don’t drive yourself) or get to a hospital ER sooner than later:
- any loss of consciousness
- altered mental status (not appearing alert or aware, unable to answer simple questions he/she should know)
- headache that won’t go away or worsens
- just plain not acting right
- any of the symptoms of severe TBI discussed above
Small children can make the situation more frightening and they can be more difficult to assess than an older child or adult. If you have any doubt at all, call 911 or go to the ER immediately. Things to look for in a child or infant include all of the signs and symptoms mentioned in this article as well as if the child is difficult to console and/or won’t eat or nurse.
If you have older children who participate in activities or a sport with a higher incidence of head injury, it’s important to educate them on the seriousness of concussions and how to recognize them. Encourage them to consider their health above a few minutes of game time.
A head injury in an elderly person always warrants a 911 call. As we get older, our brain starts to shrink, with the rate of shrinkage increasing after age 60. A head injury around/after this age has a greater chance of more severe damage to the brain and blood vessels around it. Blood thinning medications, taken by patients with a variety of medical conditions, substantially increase the risk of a bleed inside the brain. An elderly patient on blood thinners who sustains a head injury is an especially serious concern and will result in an upgraded trauma level at the ER (a higher trauma level being more serious).
Treating a Concussion
Immediate Treatment
Initial care for a head injury is limited. The first thing to consider is your and/or the injured person’s safety. Depending on what caused the head injury, you may need to get out of harm’s way before doing anything else.
Keep neck straight and still. While you’re apt to only think about the brain when it comes to a concussion, the injury could have also damaged the spine within the neck. Spinal damage already sounds bad, but there is special concern for damage to the cervical spine (commonly referred to as the c-spine) that runs from the base of your skull to the top of your back. Among the many nerves that travel down the spinal cord, the phrenic nerve — which controls the diaphragm, the primary muscle of respiration — originates in the spinal column in the neck between the 3rd and 5th cervical vertebrae. Damage to this nerve from c-spine injury can range from difficulty breathing to total diaphragmatic paralysis.
So keeping the neck of a head injury victim immobilized while waiting on EMS is vitally important. This is especially true if there is any neck pain, but an absence of neck pain does not mean there is no neck injury; to be on the safe side, always assume there is. If you’re by yourself and injured, do your best not to move your neck and head more than absolutely necessary. If you’re with someone who is injured, encourage them to remain still and keep their head straight. While positioned at the patient’s head, you can also use your hands to physically keep their head and neck in a straight line, using your palms and fingers to provide support to the head and neck and prevent forward and lateral movement. When EMS arrives, they will assess the need to continue providing what we call “c-spine precautions” or “c-spine immobilization” based on what you or the patient can tell them of the incident. If they choose to continue with c-spine precautions, they will put a stiff collar around the patient’s neck (a cervical or c-collar) that helps keep the neck straight.
Control bleeding if a laceration is present. If a laceration is present, control the bleeding with enough pressure to stop it. Don’t be shocked or surprised if a relatively small laceration seems to bleed a lot. The scalp and face have numerous superficial blood vessels and damage to these areas is therefore likely to bleed more than a similarly sized cut on your arm. Using a gauze roll that you can wrap around the head (keeping the entire spine inline and minimizing head/neck movement as you do so) can help keep the bandage in place. (Surely you have a gauze roll handy because you keep a well-stocked first aid kit at the ready and know how to use everything in it, right?) But don’t delay definitive treatment just to do your own bandaging, and don’t do anything you haven’t trained for or aren’t comfortable with. Treat swelling and goose eggs with ice. If you notice a depressed area of the skull, avoid applying pressure to this area; if you need to control bleeding in this area, use extreme caution.
Begin CPR, if necessary/advisable. Some head injuries can be severe enough that the patient is knocked unconscious and their breathing rate may be slowed. If the patient doesn’t appear to be breathing, feel for a pulse. If they don’t have a pulse and you have the proper training, initiate CPR. An emergency dispatcher may also direct you to perform CPR.
If they do have a pulse but they’re not breathing or their breathing is inadequate, there’s very little that a layperson can do. Mouth to mouth is not encouraged anymore for several reasons, including risk of disease transmission and the risk of inexperienced or untrained persons inadvertently blowing air into the stomach instead of the lungs, which can cause vomiting and subsequent aspiration of the vomitus.
At the ER, depending on the severity of the injury, the symptoms present, and the past medical history of the patient, the doctor may order a CT scan (sometimes called a CAT scan) to examine the brain and/or spinal cord and look for evidence of damage, swelling, bruising, or bleeding in the brain. A CT with negative findings (nothing found) does not mean that you don’t have a concussion, but rather rules out other, more dangerous, diagnoses. A diagnosis of a concussion is made based on the physical exam and history of the incident.
Post-Incident Treatment
Once you’ve been discharged and diagnosed with a concussion, there are a few things you can do to aid in recovery:
Rest. Just like muscles need to rest to recover after a workout or an injury, your brain also needs time to rest to recover. This includes mental rest — reducing stress — as well as physical rest. Limit exercise too, while recovering, and don’t do anything that could cause your brain to be jostled around at all. Take a few days off of work or school if possible. Don’t participate in sports (especially contact) while symptoms persist. And contrary to popular belief, it is okay to sleep following a concussion, as long as the person is alert and acting normal before they go to bed.
Diet. Maintaining a healthy diet is always important, but especially so after an injury. The many vitamins, minerals, and nutrients in a balanced diet will assist in recovery.
Lights and sounds. Limit exposure to bright lights and loud sounds. You may be sensitive to light and sound anyway, so this will come as a no-brainer in those cases. Even if you don’t experience this sensitivity, reducing exposure will assist in your brain’s recovery. This includes limiting your screen time to reduce eye strain from staring at your phone, tablet, computer, or television.
Doctor’s orders. Above and beyond these recommendations, follow your doctor’s advice and be sure to ask about how your concussion relates to your specific situation, needs, and medical history.
Conclusion
While the causes and signs of a concussion and other head injuries can vary, they should always be taken seriously. There is no such thing as a “minor” brain injury and any impact to our heads should be met with an abundance of caution. By understanding your risks, recognizing the symptoms, and knowing what to do, you will be better equipped if this unfortunate situation arises. Be confident, keep your cool, and stay manly.
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